Journal of Obesity & Metabolic Syndrome 2019;28:225-235

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Nutritional Management in Childhood Obesity

Jieun Kim1, Hyunjung Lim1,2,*
Research Institute of Medical Nutrition, Kyung Hee University, Seoul; 2Department of Medical Nutrition, Graduate School of East-West Medical Science, Kyung Hee
1

University, Yongin, Korea

The increasing prevalence of overweight and obese children and adolescents poses a major concern worldwide.
Received  October 20, 2019
Dietary practice in these critical periods affects physical and cognitive development and has consequences in Reviewed  November 13, 2019
later life. Therefore, acquiring healthy eating behaviors that will endure is important for children and adoles- Accepted  December 9, 2019
cents. Nutrition management has been applied to numerous childhood obesity intervention studies. Diverse
*Corresponding author 
forms of nutrition education and counseling, key messages, a Mediterranean-style hypocaloric diet, and nutri-
Hyunjung Lim
tional food selection have been implemented as dietary interventions. The modification of dietary risk in terms
of nutrients, foods, dietary patterns, and dietary behaviors has been applied to changing problematic dietary
factors. However, it is not easy to identify the effectiveness of nutritional management because of the complex https://orcid.org/0000-0001-7632-7315
and interacting components of any multicomponent approach to intervention in childhood obesity. In this re- Department of Medical Nutrition,
view, we describe the modifiable dietary risk factors and nutritional components of previous nutrition interven- Graduate School of East-West Medical
tion studies for nutritional management in childhood obesity. Furthermore, we suggest evidence-based prac- Science, Kyung Hee University, 1732
Deogyeong-daero, Giheung-gu, Yongin
tice in nutrition care for obese children and adolescents by considering obesity-related individual and environ- 17104, Korea
mental dietary risk factors. Tel: +82-31-201-2343
Fax: +82-2-969-7717
E-mail: hjlim@khu.ac.kr
Key words: Pediatric obesity, Nutrition therapy, Diet therapy  

INTRODUCTION established in early childhood and continue into adulthood.7 Poor

The childhood obesity epidemic has reached 124 million indi-
viduals, and nearly one in five children and adolescents are over-
weight or obese. The worldwide trend in childhood obesity shows
1
a steadily increasing body mass index (BMI) in children and ado-
lescents across four decades. In East and South Asia, including
South Korea, the BMI increase among children and adolescents
has accelerated since 2000. The prevalence of obesity in children
2
and adolescents increased from 11.6% in 2008 to 17.3% in 2017.
Obesity in early life is of concern due to health consequences and
its influence on later life. Increased adiposity levels are strongly as-
4
sociated with developing metabolic disorders and signs of adverse
cardiometabolic diseases. The severity of these comorbidities typi-
5
cally increases with the severity of the obesity.6
Dietary- and health-related behaviors and food preferences are
food choices and overconsumption are associated with a higher
risk of developing obesity.8 The prevalence of diet-related metabol-
ic disorders such as obesity, glucose intolerance, elevated blood
pressure, and dyslipidemia is increasing due to unbalanced food in-
take among adolescents.9 Dietary factors are the most important
factors associated with childhood obesity,10 and prevalence rates of
nutrition-related noncommunicable diseases such as obesity and
diabetes in children and adolescents have prompted prioritizing
3
healthy diets.1
Dietary intervention and multisectoral approach intervention
studies have reported positive changes in body composition and
dietary factors for overweight and obese children and adoles-
cents.11-16 Dietary components such as energy-dense foods, sugar-
sweetened beverages (SSBs) and patterns of processed food con-
sumption are discussed among the modifiable risk factors associat-

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J Obes Metab Syndr 2019;28:225-235 http://www.jomes.org  |  225

Kim J, et al.  Nutritional Management in Childhood Obesity

ed with obesity in children and adolescents.17-19 In the present re-
view, we describe the dietary risk factors associated with childhood
obesity and summarize the previous efforts at nutrition manage-
ment in multisectoral interventions. In addition, we suggest cus-
tomized nutrition care for obese children and adolescents to im-
prove young children’s dietary factors.
DIETARY RISK FACTORS IN CHILDHOOD
OBESITY
Numerous diet-related modifiable risk factors (nutrients, foods,
dietary patterns, and eating behaviors) have been considered in
previous clinical research studies and suggested in guidelines on
childhood obesity (Table 1). A higher intake of saturated fats and
carbohydrates, including the overconsumption of energy-dense
foods such as pizza, soda, and SSBs, has been associated with obe-
sity in children and adolescents.20,21 Dietary patterns during child-
hood have identified associations between diet and diseases such
as diabetes, hypertension, cardiometabolic risk, and childhood
obesity.4,18,22 The Western dietary pattern, which contains high
amounts of saturated fatty acids, is energy-dense, is micronutrient
poor, and is limited in non-starch polysaccharides (fiber), is known
to be a dietary risk factor encouraging childhood obesity.
patterns that are rich in meat, soda, fried food, instant noodles,
burgers, and pizza increased the risk of obesity by 30% compared
to diet patterns rich in whole grains, legumes, potatoes, fish, mush-
rooms, seaweed, fruits, and vegetables.24
Unhealthy eating habits and patterns formed during childhood
have been associated with nutrition-related noncommunicable dis-
eases such as obesity and diabetes.25 Sedentary behavior among
children and adolescents, higher intake of snacks, consumption of
SSBs, fast food consumption, eating while watching television,
skipping breakfast, reduced numbers of family meal times spent
eating together, and lower daily intake of milk, fruits, and vegetables
have all been associated with increased rates of childhood obesity,
leading to adverse health and dietary outcomes.26,27
Meanwhile, an adequate nutritional intake of vitamins and min-
erals, whole grains, milk and dairy products, fruits, and vegetables
in a balanced diet has been found to not only protect growth but
also manage childhood obesity.17,28-31 In addition, it is recommend-
ed that proper dietary behaviors with family support include meals
at home, eating together as a family, regular mealtimes, and portion
sizes appropriate for the daily requirements of children and adoles-
cents.19,32,33
NUTRITION-BASED MULTIDISCIPLINARY
INTERVENTION COMPONENTS
AFFECTING CHILDHOOD OBESITY
Systematic reviews have suggested that multiple strategies and
17,23
Diet components and a multilevel approach that focuses on diet and
health-related activities have provided the most sustainable and
beneficial effects on childhood obesity intervention, rather than
single-component interventions.34,35 Furthermore, social support
such as individualized coaching, text messaging, face-to-face com-
munication, and Internet-based approaches with a theoretical back-

Table 1. Diet-related modifiable factors affecting childhood obesity

Factor Harmful Beneficial
Nutrient - Excessive intake of total energy, proteins (from animal products), - Adequate intake of vitamins C and D, non-starch polysaccharides
fat, saturated fat, sodium17,28 (fiber), calcium, folate, iron17,29,36
Food - Excessive intake of energy-dense foods: pizza, fast food, discretionary - Adequate intake of whole grains30,31
food, soda, sugar-sweetened beverages, and ice cream23,27,34 - Low daily consumption of milk, fruits, vegetables, fish37,38
Dietary pattern - Westernized dietary patterns high in saturated fatty acids, dense in - Balanced diet based on five food groups17,28-31
energy, and poor in micronutrients17,18,23 - Stop-light/traffic-light diet, with food divided into three categories:
- Processed food dietary patterns, including meat, soda, fried food, green (low-energy, high-nutrient foods), yellow (moderate-energy
instant noodles, burgers, and pizza24 foods), and red (high-energy, low-nutrient foods)39,40
Dietary behaviors and eating habits - Eating while watching TV19 - Family mealtimes, eating together19,32
- Skipping breakfast26,27 - Portion control29,33
- Frequent snacking and eating19 - Regular mealtimes19,32,33
Guidelines and recommendations17-19,23,24,26-34,36-40 of diet-related modifiable factors for nutritional management in childhood obesity.

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Kim J, et al.  Nutritional Management in Childhood Obesity
ground have been adapted to change obesity-related dietary behav-
iors in children and adolescents.12-16,41-43 The most promising ap-
proaches for childhood obesity management are intervening with
support at levels ranging from individual to community via sustain-
able and multisectoral strategies. 44
Let’s Move was a program of the U.S. government in collabora-
tion with the American Academy of Pediatrics intended to provide
Internet-based resources for BMI and diet and to develop activity
screening in primary care, including counseling and advocacy
methods for healthcare professionals.11 Consistent with this initia-
tive, innovative use of health information technology was imple-
mented via individualized coaching for behavior change, text
messaging to provide outreach support for obesity management,41
and study-specific website and email programs, which had achieve-
ments similar to those found with face-to-face support. 42
The B’More Healthy Communities for Kids trial was a multilevel
childhood obesity prevention intervention guided by social cogni-
tive theory, social ecology, and systems theory. According to these
theories, psychosocial factors, social-environmental factors, and
physical factors interact at multiple levels to shape health-related
outcomes. In this study, wholesalers, corner stores, take-out res-
13
taurants, recreation centers, and households worked together to
improve availability, purchasing, and consumption of healthier
foods and beverages (low sugar, low fat) in low-income African
American zones in the city of Baltimore, MD, USA. 13
The Childhood Obesity Demonstration (CORD) project was
designed to cover 4 years, including three grantees, Massachusetts
(MA CORD), California (CA CORD), and Texas (TX CORD),
funded by the Centers for Disease Control and Prevention. This
set of three unique multilevel, multi-setting demonstration projects
aimed to prevent childhood obesity by supporting healthy eating
and active living among 2- to 12-year-old children. The results from
the MA CORD study included changes in organizational policies
and environments to better support healthy living and improve-
ments in health behaviors of children, parents, and stakeholders.
The identification and prevention of dietary- and lifestyle-in-
duced health effects in children and infants (IDEFICS) study was
developed by eight European countries to implement and evaluate
diet- and lifestyle-related diseases and was strongly focused on
childhood obesity in a large population-based cohort of 16,228 Eu-
J Obes Metab Syndr 2019;28:225-235
ropean children aged 2 to 9 years.16 The IDEFICS intervention fo-
cused on the three main concepts of nutrition, physical activity, and
stress, and it formulated six key messages. The prospective study
reported that children consistently allocated to the “processed”
cluster increased their BMI, waist circumference, and fat mass gain
compared to children allocated to the “healthy” cluster. Being in
the “processed”–“sweet” cluster combination was also linked to in-
creased BMI, waist circumference, and fat mass gain over time
compared to the “healthy” cluster.43
RECENT DIETARY INTERVENTIONS AND
12
OUTCOMES
We performed a systematic review of the literature for identify-
ing the effectiveness of nutritional interventions using the electron-
ic databases PubMed, Cochrane Library, and Web of Science, cov-
ering the past 5 years (2015 through August 2019). The following
search terms were used: childhood obesity, obese children and ad-
olescents, nutritional intervention, and dietary outcomes. Trials
published in English were included in this study; the primary out-
comes examined were energy, nutrient intake, fruit and vegetable
consumption, and dietary behaviors.
Dietary interventions
Only articles on dietary outcomes were extracted from the data-
bases by two researchers. Six studies45-50 are summarized in Table 2
among the dietary intervention studies that were selected by titles
and abstracts. Nutritional components (nutrition education, key
14
messages, Mediterranean-style hypocaloric diet, and nutritional
food selection) and outcomes (energy and nutrient intake; fruit,
vegetable, and dairy product consumption; and dietary behaviors)
of the dietary intervention studies are presented in Table 2.
Nutrition education was delivered by health instructors at select-
ed schools. Face-to-face training was used, with a book for guid-
15
ance when necessary, for weekly nutrition sessions for the partici-
pants. Monthly lifestyle education sessions focusing on childhood
obesity and its causes, cooking methods, and plans to reduce inac-
tivity were provided to parents of the participants.45 Curtin Univer-
sity’s Activity, Food and Attitudes Program (CAFAP) study fo-
cused on healthy food choices and key messages: eat more fruit;
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Kim J, et al.  Nutritional Management in Childhood Obesity

eat more vegetables; and eat less junk food. Regarding general nu- the key topics reinforced in each session, delivered in 12 group edu-
tritional themes, energy balance, food labeling, diet variety, fast cation sessions with parents and adolescents together. Parents took
food, lunchbox food, portion size, and recipe modification were part in nutritional sessions and in practical training in shopping at a

Table 2. Changes in dietary factors and weight status of children and adolescents after participating in nutritional interventions
Study Subject Duration Intervention Nutritional component Outcome*
Amini et al. (n= 334) 18 wk Nutrition education and (1) Provided face-to-face training, the book Only the intervention reduced BMI z-score
(2016)45 Fourth to sixth increased PA for the pupils, General Knowledge of Nutrition whenever
grades, lifestyle modification for the necessary, and a guide for health
overweight parents, and changes in food instructors; 15 to 45 minutes, once a
or obese, items sold at the schools’ week; 12 weekly sessions; concepts of
based on cafeterias. overweight and obesity, food groups
World Health and energy, and obesogenic situations
Organization and strategies to overcome them
standards (2) No nutrition education
Smith et al. (n= 69) 8 wk (follow-up Twice-weekly group sessions 12 Group education sessions with parents Energy intake (kJ)↑, protein (g)↑, fat (g)↑,
(2015)46 Aged 11–16 12 mo) at local community site and adolescents together regarding saturated fat (g)↓, carbohydrate (g)↓,
years, a BMI (CAFAP) targeting the PA, general nutrition, energy balance, food sugar (g)↓, fiber (g)↑
for age and sedentary behavior, and labeling, diet variety, fast food, lunchbox Self-reported eating behaviors↑
sex above healthy eating behaviors of food, portion size, and recipe modification, Frequency of breakfast↓, frequency of fast
the 85th overweight adolescents with the key messages reinforced in food↓, frequency of sweetened
percentile each session; cooking classes focusing beverages↓, perceived daily fruit
on the preparation of healthy foods servings↑, perceived daily
containing fruits and vegetables Vegetable servings↑
Ojeda-Rodríguez (n= 107) 8 wk (follow-up (1) Moderate hypocaloric (1) Children were taught several topics (1) Energy (kcal/day)↓, Carbohydrate (g/day)↓,
et al. (2018)47 Aged 7–16 22 mo, Mediterranean diet and such as food preparation, portion Fiber (g/day)↑, Protein (g/day)↓, Total Fat
years, waist ongoing); received nutritional control, eating behavior, food (g/day)↓
circumference data present education composition. Intensive care participants Fruits (g/day)↑, vegetables (g/day)↑,
above only for 8 wk (2) A 30-min individual session followed a Mediterranean-style diet dairy products↑, meat (g/day)↓, fish (g/
the 90th with the dietitian and five based on high consumption of fruit, day)↑, sweets (g/day)↓
percentile monitoring visits to assess vegetables, whole grains, legumes, (2) Energy (kcal/day)↓, carbohydrate (g/day)↓,
according to anthropometric parameters nuts, seeds, and olive oil, minimally fiber (g/day)↑, protein (g/day)↓, total fat
national processed foods; moderate (g/day)↓
data consumption of dairy products, fish, Fruits (g/day)↑, vegetables (g/day)↑,
and poultry; and low consumption of dairy products↑, meat (g/day)↓, fish (g/
red meat. day)↑, sweets (g/day)↓
Significant reduction in BMI standard
deviation score in both groups
Kustiani et al. (n= 90) 5 wk (1) Nutrition education and PA Nutrition education intervention was (1) Fiber intake↑
(2015)48 Aged 10–15 intervention conducted for 30 minutes every week. (2) Fiber intake↑
years, obese (2) Nutrition education and Intervention of fruit was conducted on (3) Fiber intake↑
fruit intervention every school day (5 times/wk) with 1–2 Body weight decreased in (1, 3)
(3) Nutrition education, PA and servings of fruit. exception of (2)
fruit intervention
Serra-Paya et al. (n= 113) 8 mo (1) Family-based Three behavior strategy sessions were (1) Fruits (pieces/day)↑, processed meats
(2015)49 Aged multicomponent behavioral designed to reinforce the acquisition of (servings/day)↓, fish (servings/day)↑,
6–12 years, intervention healthier PA and eating habits within the vegetables (servings/day)↑, legumes/
overweight (2) Usual advice from their family. pulses (servings/day)↑, superfluous
or obese pediatrician on healthy foods (servings/day)↓, sugar-sweetened
eating and PA juices and soft drinks (servings/day)↓
(2) Fruits (pieces/day)↑, processed meats
(servings/day)↓, fish (servings/day)↓,
vegetables (servings/day)↑, legumes/
pulses (servings/day)↑, superfluous
foods (servings/day)↓, sugar-sweetened
juices and soft drinks (servings/day)↓
No significant difference of BMI between
the two groups at post intervention
(Continued to the next page)

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Kim J, et al.  Nutritional Management in Childhood Obesity
Table 2. Continued
Study Subject Duration Intervention
Llauradó et al. (n= 349) 4-yr follow-up Twelve educational
(2018)50 13- to intervention activities that
15-year-old focused on eight lifestyle
adolescents topics selected based on
with scientific evidence to
childhood improve nutritional food
obesity selection, healthy habits,
and overall adoption of
behaviors that encourage PA
*Outcomes: (after the intervention) ↑: increase, ↓: decrease.
PA: physical activity; BMI, body mass index; CAFAP: Curtin University’s Activity, Food and Attitudes Program.
supermarket and cooking classes for healthy foods such as fruits
and vegetables.46
The Intervention Grupo Navarro de Estudio de la Obe- sidad
Infantil study consisted of an 8-week phase and a 2-year follow-up
program. The usual care group received standard pediatric recom-
mendations and anthropometric measurements, while the inten-
sive care group was advised to adhere to a Mediterranean-style hy-
pocaloric diet. Nutritional theme-based topics included controlling
healthy lifestyle behavior, food preparation, portion control, eating
behavior, food composition, and the importance of being physical-
ly active during leisure time. In addition, information on healthy
lifestyles and how to manage obesity-related problems was provid-
ed to the caregivers by dietitians. 48
The Nereu Program (NP) was an intensive, 8-month, family-
based, multicomponent behavioral intervention on healthy eating
and physical activity in 6- to 12-year-old children who were over-
weight and obese. The NP consisted of the following four compo-
nents: physical activity, family theoretical and practical training for
parents, a behavioral component for both children and parents, and
activities. For the usual treatment group, a 10-minute monthly fam-
ily meeting based on the same NP components was provided over
an 8-month period. Based on the food frequency questionnaire
and main nutritional characteristics, the intervention addressed the
following foods for participants and their families: all fruits, which
have high levels of antioxidants, fiber, and vitamins; processed
meats, which contain fatty acids; superfluous foods characterized
by a high level of lipid content and/or simple sugars; and soft
drinks, which have a high simple sugar content without nutrients.49
J Obes Metab Syndr 2019;28:225-235
Nutritional component Outcome*
(1) To encourage the intake of healthy Only the intervention girls showed reduced
drinks (and the avoidance of unhealthy BMI z-scores.
carbonated sweetened beverages)
(2) To increase the consumption of
vegetables and legumes
(3) To decrease the consumption of
candies and pastries while increasing
the intake of fresh fruits and nuts
(second year)
(4) To increase fruit intake
(5) To improve dairy product consumption
and to increase fish consumption
The school-based Educació en Alimentació (the EdAl study)50
program was designed to verify the sustainability of the benefits
from a previous EdAl study by assessing the obesity-related out-
comes and lifestyles of 13- to 15-year-old adolescents. The EdAl
program was comprised of 12 educational intervention activities
that were based on improving health-related habits such as nutri-
tional food selection, hand washing, and avoiding sedentary behav-
ior.50
Outcomes
Energy and nutrient intake
Two studies reported higher energy, protein, and fat intake after
the intervention compared to baseline.45,46 Despite the lack of posi-
tive changes in macronutrient intake, lower levels of saturated fat
and sugar consumption were presented in the CAFAP cohort
study. In another multidisciplinary intervention study, lower energy
intake and macronutrient intake were reported after the dietary in-
tervention (at 8 weeks) in both the usual care group and the inten-
sive care group.47
Consumption of fruits, vegetables, and dairy products
Improvements in consumption of fruits and vegetables among
the children and adolescents were reported in three of the multi-
component-approach intervention studies.46-49 Smith et al.46 stated
that perceived fruit consumption and vegetable consumption of
the participants were higher after the dietary intervention. Ojeda-
Rodríguez et al.47 and Serra-Paya et al.49 presented higher levels of
dairy product consumption as well as fruit and vegetable consump-
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Kim J, et al.  Nutritional Management in Childhood Obesity
tion after the intervention in both groups. Meanwhile, a 4-year fol-
low-up study showed decreased consumption of dairy products,
fruits, and fish among children and adolescents.50
Unhealthy dietary behaviors
Lower consumption levels of sugar-sweetened juices and soft
drinks and sweet, superfluous foods (cookies, pastries, dairy-based
desserts, and French fries, which contain high levels of lipids and/
or simple sugars) were shown after the dietary intervention in three
of the preceding studies.46,47,49
Body composition
Most of the studies showed decreased BMI z-scores of obese
children and adolescents after 6 weeks to 6 months for each of the
intervention studies. Theme-based nutritional sessions, involving
portion size and food groups,51 feelings of hunger and satisfaction,52
nutrition counseling and phone calls,53 nutrition education group
sessions and leaflets for caregivers, healthful and balanced diet
54
with fruits and vegetables, and healthy beverage intake and in-
55
creased consumption of fruits, nuts, legumes, vegetables, fish, and
dairy products were implemented in childhood obesity interven-
50
tion studies (data not shown).
Figure 1. Nutrition Care Process and Model. Academy of Nutrition and Dietetics. Adapted from Lacey and Pritchett. J Am Diet Assoc 2003;103:1061-72, with permission
from Elsevier.56
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EFFECTS OF INDIVIDUALIZED
NUTRITIONAL MANAGEMENT ON
CHILDHOOD OBESITY
There are numerous risk factors for obesity in children and ado-
lescents, and these factors interact with a high level of complexity.
The nutritional care process model (NCP)56 (Fig. 1) could be
adapted well to this complex task through dietitian-delivered life-
style interventions.57 The Academy of Nutrition and Dietetics de-
veloped the NCP, a highly qualified systematic approach to care, by
employing four interrelated steps: nutritional assessment, diagno-
sis, intervention, and monitoring/evaluation. There is a requirement
for standardizing the NCP and increasing the quality and consis-
tency of nutritional care by using the International Dietetics and
Nutrition Terminology (IDNT).58,59 Previously, we developed a
study protocol60 to manage the dietary problems of moderately to
severely obese children and adolescents by adopting the NCP and
IDNT. Three general domains—nutrition intake, nutrition clinical,
and nutritional behavioral—were employed for nutritional diagno-
sis (Table 3). Nutrition diagnosis is the act of identifying a disease
or condition from its signs and symptoms by a dietetics profession.
An identified nutritional problem is summarized into a structured
J Obes Metab Syndr 2019;28:225-235
Kim J, et al.  Nutritional Management in Childhood Obesity
Table 3. Adoptable nutrition diagnosis of NCP components employed while using IDNT for childhood obesity
Domain
Nutrition intake*: actual problems related to intake of
energy, nutrients through eating
Nutrition clinical†: nutritional findings/problems identified
that relate to medical or physical conditions
Nutrition behavioural‡: nutritional findings/problems
identified that related to knowledge, attitude/belief,
physical environments, access to food, or food safety
*Defined as “actual problems related to intake of energy, nutrients, fluids, bioactive substances through oral diet or nutrition support”; †Defined as “nutritional findings/problems re-
lated to medical or physical conditions”; ‡Defined as “nutritional findings/problems that relate to knowledge, attitudes/beliefs, physical environment, access to food, or food safety.”
NCP, nutritional care process model; IDNT, International Dietetics and Nutrition Terminology; DRI, dietary reference intake; FBG, fasting blood glucose; BMI, body mass index.
sentence called a PES (Problem, Etiology, Symptom) statement.
This statement is linked by the connecting terms problem/nutri-
tion diagnosis related to etiology as evidenced by the signs and
symptoms. The identified etiology, signs and symptoms point to a
certain type of nutrition intervention and monitoring/evaluation
that is needed. It is an important process in the implementation of
a nutrition intervention and monitoring/evaluation of the NCP. A
structured recommendation for nutritional management of child-
hood obesity was presented as a tool in another research study that
helped practitioners structure their actions according to the four
interrelated steps of the NCP model. This practice-based, evidence-
informed approach assisted not only the dietitians but also the pro-
fessionals in pediatric obesity. The NCP four-step structured
framework made it possible to structure patient-centered nutrition-
al care and management of childhood obesity. 61
CONCLUSION
Dietary intervention with a multisectoral approach has had posi-
J Obes Metab Syndr 2019;28:225-235
IDNT Nutrition diagnosis
Excessive energy intake Related to unwillingness in reducing intake as evidenced by excessive energy
intake compare with DRIs
Excessive oral intake Related to lack of value for behaviour change or competing values as evidenced by
intake or overconsumption of energy-dense foods for meal (or snack)
Excessive fat intake Related to limited access to healthy food choice, as evidenced by frequent high-fat
food intake (or overconsumption)
Excessive carbohydrate intake Related to food and nutrition knowledge deficit as evidenced by FBG > 120 mg/dL
or continuous carbohydrate overconsumption compared with DRIs
Obesity As evidenced by BMI for sex, age: ≥ 95th %tile
Food- and nutrition-related Related to lack of prior exposure to accurate nutrition-related information, as
knowledge deficit evidenced by deficit in food and nutrition-related recommendations knowledge
Not ready for diet/lifestyle Related to denial of need to change, as evidenced by negative attitude and facial
change expressions or failure to make a future visit
Self-monitoring deficit Related to unwillingness or disinterest in tracking progress, as evidenced by anger
or embarrassment about changes based on self-monitoring
Limited adherence to Related to lack of value for behaviour change or competing values, as evidenced by
nutrition-related low or irregular compliance about planning
recommendations
Inability or lack of desire to Related to not being ready for diet/lifestyle change as evidenced by lack of
manage self-care confidence about changes, based on self-monitoring record
tive outcomes in modifying obesity-related dietary risk factors for
obese children and adolescents. Excellent results from previous
meta-analyses have reported a reduction in SSB intake and changes
in body fatness,62 reduction in high-fat food and sugary beverages,
increased intake of fruits and vegetables, reduction in snacks, and
maintenance of a balanced diet.63
These positive changes were found immediately after the inter-
vention; however, unfavorable outcomes were reported after long-
term follow-up in terms of weight fluctuation, increased energy in-
take, macronutrient intake, and unhealthy dietary behaviors. Fur-
thermore, it is hard to distinguish isolated impacts of nutrition care
in childhood obesity because of the complex and interacting com-
ponents of the multidisciplinary interventions.64 Behavioral modifi-
cation and motivational interviewing on the health and diet of chil-
dren and adolescents, to improve their self-control and mindful
eating for sustainable healthy weight and nutritional status, are re-
quired to provide nutritional education and management.
From this viewpoint, evidence-based practice in dietary problem
solving can suggest effective methods by considering behavioral
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Kim J, et al.  Nutritional Management in Childhood Obesity
and environmental risk factors in a diet and providing tailored nu-
tritional therapy according to the stages of change among children
and adolescents. In spite of these beneficial effects, we are facing
barriers to providing this intervention due to the time and cost of
developing more methods for countering childhood obesity. For
this reason, individual, familial, social, and political-level involve-
ment are recommended for effective and sustainable nutritional
management of childhood obesity. In addition, practical key mes-
sages for health and diet may be helpful in establishing healthful
habits and lifestyles in this public health crisis.
CONFLICTS OF INTEREST
The authors declare no conflict of interest.
ACKNOWLEDGMENTS
We thank Seran Choi and Nayoung Kim from Kyung Hee Uni-
versity for assisting with the review and identifying recent interven-
tion studies.
AUTHOR CONTRIBUTIONS
Study concept and design: HL; analysis and interpretation of
data: JK; drafting of the manuscript: all authors; critical revision of
the manuscript: all authors; administrative, technical, or material
support: JK; and study supervision: HL.
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